Why would a residency only have internal moonlighting and not allow external moonlighting

[olivarynucleus]

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Is it to control the purse strings? I feel like this is a situation where the residents that they "like" for whatever reason will get more opportunities and more money, whereas the residents that they don't like would get limited options and less money. And whether or not somebody likes you is very subjective. Also, would this type of arrangement leave residents competing against one another and breeding a hostile work environment.

 

[olivarynucleus]

Because internal moonlighting means coverage for their own services, and moonlighting hours are capped by the 80 hr work week.

So if they allow external moonlighting that means the residents wont be exclusively covering the hospital's own services and will potentially be short coverage. Particularly if there are Cush external gigs that pay well for little work.

I don't get it, then why not just mandate the residents work more? The particular program I am questioning has residents working 50 hrs a week ( psychiatry) in intern year, I would guess they would work less in years 2-4.

 

[Wordead]

I don't get it, then why not just mandate the residents work more? The particular program I am questioning has residents working 50 hrs a week ( psychiatry) in intern year, I would guess they would work less in years 2-4.

If you're a top applicant are you gonna rank the program that has you working 80/week higher or the program that works you 50/hr and lets you earn extra money on the side?

 

[NotAProgDirector]

There may be some "reasonable" explanations. For example, for internal moonlighting I can still supervise you, and cover your medmal, etc. I've had residents who moonlight extrenally and then something bad happens -- you could easily lose your residency spot (i.e. your medical license could get pulled, etc). I have heard of residents who moonlight externally and get put in bad situations -- managing something they have no business managing because there is no backup.

 

[VA Hopeful Dr]

I would've loved internal moonlight for all the reasons that aPD just mentioned. All of my stuff was external and I get pretty nervous more than a few times covering the state psych hospital on weekends.

 

[NotAProgDirector]

Rereading this thread reminded me of a specific story. One of my PGY-3 residents signed up to moonlight at one of our local small ED's. He figured he was well trained enough to handle anything that would come in the door of a small 6-10 bed ED.

... and in came a 6 month old with a high fever. He asked the nurses who the pediatric backup was, to discover there wasn't one. So he called the ped resident here to talk him through how to do an LP on a 6 month old. He cancelled all future shifts the next morning.

 

[typhoonegator]

All of the above is great. External moonlighting is an immediate push forward int0 the real world. You're a licensed physician practicing medicine without supervision with a full medical license and full legal responsibility over your actions. The training wheels are completely off the minute you show up for a shift. It's up to you to see past the $$ and decide whether it is something you're comfortable doing. The people on the other side are just trying to fill slots -- they don't (usually) care about your training progression or transition to autonomy.

Internal moonlighting is a way for programs to fill shifts that may not be universally liked or may be more scut-filled than they would typically allow in a standard rotation, but where there are enough people who are thirsty for $$ or interested enough in a particular subspecialty that they're willing to do it for either the money or the face-time or both. You make a little money, the residency fills a "float" role or something like it, and everyone wins. The difference is that everyone involved is still interested in your overall career progression, and understands your level of training. The downside is that the price per hour is almost always less than you would make doing external moonlighting. You can get sued very successfully for malpractice as a resident doing your usual work under supervision (depending to some degree on where you are training), but in general there are more protections in place doing internal moonlighting than you would ever see for doing moonlighting work for an external entity.

Bottom line: everyone likes a little WAM (walking around money), but you need to be very clear on your additional risk exposure for taking on that responsibility. I can't speak to the program giving supposed preference to particular individuals for these internal slots.

 

[link2swim06]

Rereading this thread reminded me of a specific story. One of my PGY-3 residents signed up to moonlight at one of our local small ED's. He figured he was well trained enough to handle anything that would come in the door of a small 6-10 bed ED.

... and in came a 6 month old with a high fever. He asked the nurses who the pediatric backup was, to discover there wasn't one. So he called the ped resident here to talk him through how to do an LP on a 6 month old. He cancelled all future shifts the next morning.

Why wouldn't you just transfer that kiddo to a pediatric specialty hospital. Give antibiotics right away, call peds hospital, do LP if you know how to. But it's not the LP that's saving his life..

Otherwise that case sounds pretty simple management.

 

[Chocolatedoc]

umm.. LP before antibiotics if possible. Please.

 

[rokshana]

Why wouldn't you just transfer that kiddo to a pediatric specialty hospital. Give antibiotics right away, call peds hospital, do LP if you know how to. But it's not the LP that's saving his life..

Otherwise that case sounds pretty simple management.

THIS. why residents shouldn't do external moonlighting until you are ready...you THINK this is easy...which is really scary...

 

[link2swim06]

THIS. why residents shouldn't do external moonlighting until you are ready...you THINK this is easy...which is really scary...

Nice job putting words in my mouth. Thanks you that, really.

I said if you have a child with likely meningitis and you don't know how to do an LP you need to get that kiddo to a higher level of care. Since there is a delay in LP if you highly suspect meningitis you should cover empirically with antibiotics. Please explain in detail how you of managed this differently.

So, let's fast forward. That PGY-3 is now an attending 6 months later. Still hasn't EVER done an LP on a 6 month old or infant. Takes the same job. How the hell do you think that is going to be much different? Sure all ERs should be staffed by people trained in EMERGENCY MEDICINE. Meaning they would have done numerous LPs on infants and would be comfortable with the procedure. That's impossible because there are many more openings in ERs than there are boarded EM people. Realize that some of these smaller EDs could easily hire a brand-new NP instead of a resident. Who would you rather managing these patients? Someone who went to nursing school and completed some online NP course or a senior resident?

Is moonlighting in the specialty you are training in probably the best situation possible? Yes. As an EM resident I have no plans on moonlighting as a radiologist or pathologist.

 

[rokshana]

Is moonlighting in the specialty you are training in probably the best situation possible? Yes. As an EM resident I have no plans on moonlighting as a radiologist or pathologist.

explains it.

 

[link2swim06]

explains it.

I love it, personal attacks because you have no intellectual argument. Strong work.

 

[KnuxNole]

Nice job putting words in my mouth. Thanks you that, really.

I said if you have a child with likely meningitis and you don't know how to do an LP you need to get that kiddo to a higher level of care. Since there is a delay in LP if you highly suspect meningitis you should cover empirically with antibiotics. Please explain in detail how you of managed this differently.

So, let's fast forward. That PGY-3 is now an attending 6 months later. Still hasn't EVER done an LP on a 6 month old or infant. Takes the same job. How the hell do you think that is going to be much different? Sure all ERs should be staffed by people trained in EMERGENCY MEDICINE. Meaning they would have done numerous LPs on infants and would be comfortable with the procedure. That's impossible because there are many more openings in ERs than there are boarded EM people. Realize that some of these smaller EDs could easily hire a brand-new NP instead of a resident. Who would you rather managing these patients? Someone who went to nursing school and completed some online NP course or a senior resident?

Is moonlighting in the specialty you are training in probably the best situation possible? Yes. As an EM resident I have no plans on moonlighting as a radiologist or pathologist.

The hospital would probably be thinking "Hmm....it'll be cheaper hiring that NP! Plus, they are more compassionate, which would increase their Press-Ganey scores! Woo-hoo!"

 

[exsanguination]

I love it, personal attacks because you have no intellectual argument. Strong work.

It's interesting man.. It appears as if rokshana has a thing against EM as a specialty. Look at his/her post history. Wouldn't waste much time responding to this one beyond your reply.

 

[rokshana]

It's interesting man.. It appears as if rokshana has a thing against EM as a specialty. Look at his/her post history. Wouldn't waste much time responding to this one beyond your reply.

you're right to some extent...IMHO the philosophy of EM training has taken a turn for the worse...the goal seems to be how fast can i get this person out of my ED...not really caring where they go, but how little time they can spend in the ED...where as previously the goal was how can i get them home and not in the hospital...the older ED docs, those that trained back in the 80s and the 90s...they still believe in this philosophy...there were ED docs that i knew when they called their admissions were legit...they had done what needed to be done (like draw cultures before giving abx) and the best thing was for the pt to be admitted....many (not all, there is always the exceptions to the rule) that have just recently finished training do what they need to do to get them out of the ED...even if its not really warranted...admitting a 45 yo with PNA when their PORT score is their age or the CURB 65 is 1...or an 80 yo who is...well 80...sure my opinion is colored by my experiences with ED docs, but have over the years interacted with 6 different EDs...and it wasn't just one place that these things happen.

And with the shortening of EM training...its not going to get better...luckily I won't have to deal with the ED very much anymore (other than to tell them the coherent person with a TSH of 30 they think has myedema coma, doesn't have myxedema coma).

 

[rokshana]

I love it, personal attacks because you have no intellectual argument. Strong work.

not a personal attack...just seems to be the mindset of the ED residents that post here...once you are an attending and the the medico-legal responsibility is on you, you won't be so flippant in your answers.

 

[VA Hopeful Dr]

not a personal attack...just seems to be the mindset of the ED residents that post here...once you are an attending and the the medico-legal responsibility is on you, you won't be so flippant in your answers.

While that's true, I think the clinical case in question was handled poorly. You don't do your first peds LP, as an IM resident mind you, on a kid with fever who you are concerned has meningitis. You start antibiotics and ship to somewhere that can actually handle the case.

I know that abx before LP isn't ideal, but you don't mess around with meningitis.

 

[RuralMedicine]

Rereading this thread reminded me of a specific story. One of my PGY-3 residents signed up to moonlight at one of our local small ED's. He figured he was well trained enough to handle anything that would come in the door of a small 6-10 bed ED.

... and in came a 6 month old with a high fever. He asked the nurses who the pediatric backup was, to discover there wasn't one. So he called the ped resident here to talk him through how to do an LP on a 6 month old. He cancelled all future shifts the next morning.

Are you an IM Program Director? The reality is that although there are many ED presentations that are completely within the IM wheelhouse so to speak most IM folks are out of their element with pediatrics and often with trauma/surgery (and with some programs to a lesser extent probably optho, ENT). But you do see job offers for EM that will take ABIM docs in a single cover ED without much (or any specialty/subspecialty backup) and I do agree that is scary.

Why wouldn't you just transfer that kiddo to a pediatric specialty hospital. Give antibiotics right away, call peds hospital, do LP if you know how to. But it's not the LP that's saving his life..

Otherwise that case sounds pretty simple management.

If I was the parent of said child, I'd certainly prefer blood/urine cultures, appropriate antibiotics, any other necessary stabilizing care and transfer to a hospital with at least an admitting pediatrician. I would not allow someone who had never done an LP on an infant to tap my child (especially not before giving antibiotics if I really thought meningitis was a possibility).

umm.. LP before antibiotics if possible. Please.

I added some emphasis and with that I would agree that ideally, sure, but in reality we often practice in less than ideal situations. If you strongly suspect meningitis then you want to do anything you can to minimize time to first dose of antibiotics. So if you have a baby with an open fontanelle and can just do the LP and get antibiotics on board then great. If you have 4 year old (or an adult) with fever and altered mental status and need a Head CT first to be sure doing the LP at all is safe then I'll be honest my usual practice is blood cultures and IV send them to CT with (+/- steroids depending on situation) Ceftriaxone hanging, I look at the CT if we're good I do the LP and then we hang the Vancomycin. The first dose of Ceftriaxone is likely not going to completely sterilize your CSF and I'd rather have it on board if I have very strong clinical suspicion.

The other reality is that we're all human. Sometimes the LP just can't be done by the ED doc, or the admitting pediatrician, etc. In that case you definitely need to give antibiotics and if someone else can get the LP later then although cultures will be low yield the cell count, and chemistries can still be useful and can exclude the meningitis diagnosis.

THIS. why residents shouldn't do external moonlighting until you are ready...you THINK this is easy...which is really scary...

I generally find your posts to be reasonable and logical so I wonder if maybe you're getting at the idea that he/she is overlooking the possibility for sepsis and not appropriately addressing that and resuscitating before transfer. If that it your point--ok, and I don't disagree. Or perhaps you are alluding to the idea that at six months clinical exams do come into play so 103/104 fever doesn't necessarily mean LP indicated and I wouldn't disagree with that either. Beyond those caveats, I do think that antibiotics and transfer to an appropriate facility with pediatrics coverage is a reasonable approach.

Nice job putting words in my mouth. Thanks you that, really.

I said if you have a child with likely meningitis and you don't know how to do an LP you need to get that kiddo to a higher level of care. Since there is a delay in LP if you highly suspect meningitis you should cover empirically with antibiotics. Please explain in detail how you of managed this differently.

So, let's fast forward. That PGY-3 is now an attending 6 months later. Still hasn't EVER done an LP on a 6 month old or infant. Takes the same job. How the hell do you think that is going to be much different? Sure all ERs should be staffed by people trained in EMERGENCY MEDICINE. Meaning they would have done numerous LPs on infants and would be comfortable with the procedure. That's impossible because there are many more openings in ERs than there are boarded EM people. Realize that some of these smaller EDs could easily hire a brand-new NP instead of a resident. Who would you rather managing these patients? Someone who went to nursing school and completed some online NP course or a senior resident?

Is moonlighting in the specialty you are training in probably the best situation possible? Yes. As an EM resident I have no plans on moonlighting as a radiologist or pathologist.

To be fair the reality is that sometimes procedures are just hard and sometimes a fresh pair of eyes and hands can make a difference. I spent a small portion of my last hospitalist shift doing an LP on one of my ICU admits that the EP (who happens to be ABEM boarded and is generally I think a competent physician) could not get the night before. They did start antibiotics (albeit not at meningitic doses but our night admitter caught that and adjusted) and got blood cultures so once I was successful with the LP and it had only 1 WBC and 0 RBCs we could pretty much exclude meningitis (and bleed which I was actually a little more concerned with given the clinical picture).

For the record, I do agree with you that staffing EDs with EM trained folk is the way to go. Unfortunately, where you see the most push to put non EM trained physicians in EDs is in rural areas where I think there is the greatest need for EM trained physicians because you are much more likely to not have much (or any) specialty/sub-specialty backup. Some of this is physician shortage and preference issue but there is also an economic issue (both in terms of financial incentives for physicians to bring them into the community and hospitals being willing/able to have resources that allow them to uphold the standard of care so they don't leave after a few scary shifts). Sadly, I've also seen a few EM staffing groups who are quite willing, and happy, to put non EM trained and not EM competent docs in these small rural EDs for as long as they can get away with it because they are both cheaper to employ and also easier to manage (because the physician who is working in a rural ED after getting kicked out of their residency may not have a lot of other options for other jobs so they will be less likely to leave even if they are paid poorly and treated worse by group administrators).

 

[TooMuchResearch]

Rereading this thread reminded me of a specific story. One of my PGY-3 residents signed up to moonlight at one of our local small ED's. He figured he was well trained enough to handle anything that would come in the door of a small 6-10 bed ED.

... and in came a 6 month old with a high fever. He asked the nurses who the pediatric backup was, to discover there wasn't one. So he called the ped resident here to talk him through how to do an LP on a 6 month old. He cancelled all future shifts the next morning.

The best part about baby LPs is the absence of several decades of fast food sitting between the needle and sweet, sweet CSF.

LP a baby? Great, no problem. Probably even has palpable landmarks.

LP a fat guy? Hey, he's probably just altered and hot because of meth, or alcohol and sun exposure, or whatever combo keeps me from having the need to dig around in his back fat.

 

[dozitgetchahi]

Is it to control the purse strings? I feel like this is a situation where the residents that they "like" for whatever reason will get more opportunities and more money, whereas the residents that they don't like would get limited options and less money. And whether or not somebody likes you is very subjective. Also, would this type of arrangement leave residents competing against one another and breeding a hostile work environment.

At least there's some sort of moonlighting involved.

At my program, moonlighting is 'discouraged'; there is no internal moonlighting whatsoever and the external moonlighting scene in this city is almost nonexistent. The few options available (our VA, LTACs) want people to have finished residency first.

I'd give anything to have some internal moonlighting jobs to fight over...

 

[Crayola227]

Rereading this thread reminded me of a specific story. One of my PGY-3 residents signed up to moonlight at one of our local small ED's. He figured he was well trained enough to handle anything that would come in the door of a small 6-10 bed ED.

... and in came a 6 month old with a high fever. He asked the nurses who the pediatric backup was, to discover there wasn't one. So he called the ped resident here to talk him through how to do an LP on a 6 month old. He cancelled all future shifts the next morning.

Just another story supporting what I'm always saying: avoid kids like the plague that they are in medicine. Do you put yourself in a position to be responsible for them medically. Ugh. I shudder.

Bottom line: everyone likes a little WAM (walking around money), but you need to be very clear on your additional risk exposure for taking on that responsibility. I can't speak to the program giving supposed preference to particular individuals for these internal slots.

On the interview trail I thought the applicants were stark raving mad asking about moonlighting... you mean, working 65 hours this week just wasn't enough for you? You're eager to find more hours to fill your time? F8ck this, I'm going home to sleep.
Then I was told how some of these shifts you take like 3 calls overnight 10 hours mostly sleeping and make like $1000. That can add add up quick!! You could double your salary easily that month. There were some residents that were almost increasing their salary by like $20,000 that year at some programs.
That was enough to make even me, who used to think that there was no amount of money that could get me to willingly spend trade one hour of sleep outside the hospital for one more hour in the hospital, stop and think twice.

However, again, the point is raised, is there any amount of money that is worth someone dying on you with no one to call? (pre-residency graduation) Is there any amount of money that would put me alone with someone else's child that needed me to provide medical care? No and no.

Why wouldn't you just transfer that kiddo to a pediatric specialty hospital. Give antibiotics right away, call peds hospital, do LP if you know how to. But it's not the LP that's saving his life..

Otherwise that case sounds pretty simple management.

Ah geez... I'll call Lifeflight with one hand and the maybe-meningitis baby in the other, and see which hand dies first... that didn't make sense. If Lifeflight were horses.... that didn't make sense. Whatever, some ENTIRE STATES will have ONE specialty peds hospital for the whole state, and if you're out in the country community hospital where your program is, 3 hours away, with Lifeflight coming to the rescue with an hour roundtrip, the possible meningitis baby is going to be in real trouble if you think you can twiddle your thumbs before you can just pass this off. The buck stops with you, and that's true whether the peds hospital is 5 min or 3 hrs away. Don't rely on anyone or any helicopter to save you and that patient.

And with the shortening of EM training...its not going to get better...luckily I won't have to deal with the ED very much anymore (other than to tell them the coherent person with a TSH of 30 they think has myedema coma, doesn't have myxedema coma).

I don't know what you mean by the shortening unless you mean the 80 hr workcaps, there are a handful of programs going from 3 to 4 years, so not shortening that way at least, but maybe that's just to make up for the work hour caps
I heard that this may become a trend for EM

and also, being coherent with a TSH of 30... the coherency does not rule out myxedema coma as there are other diagnostic criteria.... lethargy alone will meet the AMS criteria, I can be coherent but lethargic, or incoherent and not lethargic, or lethargically coherent
myxedema coma is frequently underrecognized, and given the mortality rate approaching 50%, should be taken more seriously IMHO
I've seen this dx dismissed too frequently because the patient wasn't "out of it" enough, we should rename the damn dz
sorry this particular dx gets my BP up

 

[link2swim06]

Ah geez... I'll call Lifeflight with one hand and the maybe-meningitis baby in the other, and see which hand dies first... that didn't make sense. If Lifeflight were horses.... that didn't make sense. Whatever, some ENTIRE STATES will have ONE specialty peds hospital for the whole state, and if you're out in the country community hospital where your program is, 3 hours away, with Lifeflight coming to the rescue with an hour roundtrip, the possible meningitis baby is going to be in real trouble if you think you can twiddle your thumbs before you can just pass this off. The buck stops with you, and that's true whether the peds hospital is 5 min or 3 hrs away. Don't rely on anyone or any helicopter to save you and that patient.

You aren't, you are treating right away with antibiotics. That's the point.

Regardless the appropriate end destination is a pediatric specialist hospital if they have likely bacterial meningitis.

Finally, I bet >95% of the US population is within an hour flight of a pediatric hospital. I doubt many residents are moonlighting in those super rural EDs.

 

[clausewitz2]

and also, being coherent with a TSH of 30... the coherency does not rule out myxedema coma as there are other diagnostic criteria.... lethargy alone will meet the AMS criteria, I can be coherent but lethargic, or incoherent and not lethargic, or lethargically coherent
myxedema coma is frequently underrecognized, and given the mortality rate approaching 50%, should be taken more seriously IMHO
I've seen this dx dismissed too frequently because the patient wasn't "out of it" enough, we should rename the damn dz
sorry this particular dx gets my BP up

Saw a myxedema coma recently that did not get picked up until the poor patient ended up in a psych unit and someone said "oh, wait, you're lethargic and intermittently psychotic and kind of delirious and have delayed reflex relaxation and think that bicycles and trains are similar because they're 'both fun' and have a TSH of 42." Everything went better than expected, but man, it should not have gotten that far. Just repeat "objective TSH level is not correlated with symptom severity and coma is just the endpoint of the process" PRN.

 

[rokshana]

Just another story supporting what I'm always saying: avoid kids like the plague that they are in medicine. Do you put yourself in a position to be responsible for them medically. Ugh. I shudder.



On the interview trail I thought the applicants were stark raving mad asking about moonlighting... you mean, working 65 hours this week just wasn't enough for you? You're eager to find more hours to fill your time? F8ck this, I'm going home to sleep.
Then I was told how some of these shifts you take like 3 calls overnight 10 hours mostly sleeping and make like $1000. That can add add up quick!! You could double your salary easily that month. There were some residents that were almost increasing their salary by like $20,000 that year at some programs.
That was enough to make even me, who used to think that there was no amount of money that could get me to willingly spend trade one hour of sleep outside the hospital for one more hour in the hospital, stop and think twice.

However, again, the point is raised, is there any amount of money that is worth someone dying on you with no one to call? (pre-residency graduation) Is there any amount of money that would put me alone with someone else's child that needed me to provide medical care? No and no.



Ah geez... I'll call Lifeflight with one hand and the maybe-meningitis baby in the other, and see which hand dies first... that didn't make sense. If Lifeflight were horses.... that didn't make sense. Whatever, some ENTIRE STATES will have ONE specialty peds hospital for the whole state, and if you're out in the country community hospital where your program is, 3 hours away, with Lifeflight coming to the rescue with an hour roundtrip, the possible meningitis baby is going to be in real trouble if you think you can twiddle your thumbs before you can just pass this off. The buck stops with you, and that's true whether the peds hospital is 5 min or 3 hrs away. Don't rely on anyone or any helicopter to save you and that patient.



I don't know what you mean by the shortening unless you mean the 80 hr workcaps, there are a handful of programs going from 3 to 4 years, so not shortening that way at least, but maybe that's just to make up for the work hour caps
I heard that this may become a trend for EM

and also, being coherent with a TSH of 30... the coherency does not rule out myxedema coma as there are other diagnostic criteria.... lethargy alone will meet the AMS criteria, I can be coherent but lethargic, or incoherent and not lethargic, or lethargically coherent
myxedema coma is frequently underrecognized, and given the mortality rate approaching 50%, should be taken more seriously IMHO
I've seen this dx dismissed too frequently because the patient wasn't "out of it" enough, we should rename the damn dz
sorry this particular dx gets my BP up

thank you for telling me about my specialty...profound hypothyroidism and myxedema coma are different things...but i guess you are the person that keeps me in business...

 

[rokshana]

Saw a myxedema coma recently that did not get picked up until the poor patient ended up in a psych unit and someone said "oh, wait, you're lethargic and intermittently psychotic and kind of delirious and have delayed reflex relaxation and think that bicycles and trains are similar because they're 'both fun' and have a TSH of 42." Everything went better than expected, but man, it should not have gotten that far. Just repeat "objective TSH level is not correlated with symptom severity and coma is just the endpoint of the process" PRN.

obviously not a coherent person...and a high TSH alone doesn't make for make for myxedema...i've seen pts with TSH levels in the 400s that function (not the best thing but not rushing them to the ICU either) and people with TSH of 30 that are hypotensive, brady and altered...the levels have to be put in context of the clinical symptoms

 

[clausewitz2]

obviously not a coherent person...and a high TSH alone doesn't make for make for myxedema...i've seen pts with TSH levels in the 400s that function (not the best thing but not rushing them to the ICU either) and people with TSH of 30 that are hypotensive, brady and altered...the levels have to be put in context of the clinical symptoms

Yeah, sorry, wasn't meant to be criticizing your example, just echoing Crayola's point about under diagnosis and expressing frustration with a rush to "functional" label. FTR, this person was coherent much of the time, but would sometimes wander off during conversations or would have to spend minutes thinking about the answer to a question like "how many kids do you have?"

 

[Crayola227]

thank you for telling me about my specialty...profound hypothyroidism and myxedema coma are different things...but i guess you are the person that keeps me in business...

I didn't know you were in endo. Kudos. The SDN specialty quiz puts that at the top of my list for some reason. I apologize if I contradicted you. Your statement is correct. So was mine.

Yes, interns have a way of keeping older and angrier and wiser docs in business.
I'm think I'm an intern that respects your specialty more than you know, which is why I have high index of suspicion for myxedema coma, and know that lethargy counts as a neurological symptom.

This was the case where I shouted fire fire fire waving around multiple piece of primary literature on the topic (that were on fire for effect)
and the patient languished while I watched powerless and infuriated

being in endo, why do you hate EM so much?

what should we all know about endo to be less annoying to endo? or to you for that matter?

 

[exsanguination]

being in endo, why do you hate EM so much?

what should we all know about endo to be less annoying to endo? or to you for that matter?

You'll find that all specialties hate EM with a fiery passion mostly because they're always angry about how we don't understand the nuances and hyper specifics of treating their patient with myxedema coma or guillAine barre or the SCIWORA patient. Pick and choose your niche diagnosis.

They especially don't realize the resource and information poor environment in which we work, how patients' are extremely unreliable historians and stewards of their own health, and how we're not only juggling their patient but 5 other critical ones.

It's a pattern in medicine that's pervasive and part of the reason why administration, nursing, and basically everybody whose not a doctor has pushed us aside and taken control of medicine as a whole.

We fight among ourselves about petty crap, instead of fighting as one. "Stupid ER doc can't even tell the difference between myxedema coma and hypothyroidism." Really? Then great, that's why you're a specialist and being paid to take call at the hospital. That doc is reaching out to you for help, and the specialist just complain and moan that we don't have such deep understanding of the craft that sometimes took them 6+ years of residency and fellowship to learn on top of many years of practicing as an attending to truly master that niche.

Doctors are screwed and I can tell you it's all of our faults

 

[Crayola227]

You'll find that all specialties hate EM with a fiery passion mostly because they're always angry about how we don't understand the nuances and hyper specifics of treating their patient with myxedema coma or guillAine barre or the SCIWORA patient. Pick and choose your niche diagnosis.

They especially don't realize the resource and information poor environment in which we work, how patients' are extremely unreliable historians and stewards of their own health, and how we're not only juggling their patient but 5 other critical ones.

It's a pattern in medicine that's pervasive and part of the reason why administration, nursing, and basically everybody whose not a doctor has pushed us aside and taken control of medicine as a whole.

We fight among ourselves about petty crap, instead of fighting as one. "Stupid ER doc can't even tell the difference between myxedema coma and hypothyroidism." Really? Then great, that's why you're a specialist and being paid to take call at the hospital. That doc is reaching out to you for help, and the specialist just complain and moan that we don't have such deep understanding of the craft that sometimes took them 6+ years of residency and fellowship to learn on top of many years of practicing as an attending to truly master that niche.

Doctors are screwed and I can tell you it's all of our faults

I almost went into EM, did quite a few rotations and subIs. I get it how it goes. It's good to see the other side.

Maybe on this thread or another is my post about how good some EDs are at resource use and work up. Some are just slammed and still do a good job keeping folks alive and admitting those who should be admitted and when I admit I don't get mad how much work is left to me if the ED doc used good EM and gen med logic reasoning to come to that conclusion.

I do get mad if the MI or stroke didn't get ASA or septic patient IVF, but again, mistakes are made. If that's a pattern, that substandard EM care but like I said I have an idea of what is reasonable to expect from the ED.

A couple times I caught myself saying, "really, why this ****ing CXR?" but again, usually I could see why with what was known in the ED at the time and maybe how busy they were, and what unlikely but dangerous thing they were looking for, that's what happened.

Everyone in medicine could be doing a better job, but I see most of the problems as systems issues as you point out.